“Can someone come turn off Mr. Smith’s pacemaker? He just found out he has terminal cancer.”

Bradley P. Knight, MD, FACC, FHRS, Editor-in-Chief
Bradley P. Knight, MD, FACC, FHRS, Editor-in-Chief
Dear Readers,     “Can someone come turn off Mr. Smith’s pacemaker? He just found out he has terminal cancer.” Physicians and other health care providers who care for patients with pacemakers and defibrillators are occasionally asked difficult questions like this, and there has been little formal guidance from professional societies on how to handle this situation. Fortunately, the first collaborative consensus statement on how to manage implantable devices in terminally ill patients was released during the 2010 Heart Rhythm Society Scientific Sessions in May. The document, entitled HRS Expert Consensus Statement on the Management of Cardiovascular Implantable Electronic Devices (CIEDs) in patients nearing end of life or requesting withdrawal of therapy, was truly a collaborative effort written by a group of electrophysiologists as well as individuals with expertise in the fields of geriatrics, palliative care, psychiatry, pediatrics, nursing, law, ethics, and divinity, and even a patient who lectures on the topic. Excerpts from the document are below: • A patient with decision-making capacity has the legal right to refuse or request the withdrawal of any medical treatment or intervention, regardless of whether s/he is terminally ill, and regardless of whether the treatment prolongs life and its withdrawal results in death. • When a patient lacks capacity, his/her legally-defined surrogate decision-maker has the same right to refuse or request the withdrawal of treatment as the patient would have if the patient had decision-making capacity. • Ethically and legally, there are no differences between refusing CIED therapy and requesting withdrawal of CIED therapy. • Legally, carrying out a request to withdraw life-sustaining treatment is neither physician-assisted suicide nor euthanasia. • Ethically, CIED deactivation is neither physician-assisted suicide nor euthanasia. When carrying out a patient’s request for withdrawal of a life-sustaining treatment that a patient perceives as unwanted (including CIED therapies), the clinician’s intent is to discontinue the unwanted treatment and allow the patient to die naturally of the underlying disease — not to terminate the patient’s life. • The right to refuse or request the withdrawal of a treatment is a personal right of the patient and does not depend on the characteristics of the particular treatment involved (i.e., CIEDs). Therefore, no treatment, including CIED therapies, has unique ethical or legal status. • A clinician cannot be compelled to carry out an ethically- and legally-permissible procedure (i.e., CIED deactivation) that s/he personally views in conflict with his/her personal values. In these circumstances, the clinician cannot abandon the patient but should involve a colleague who is willing to carry out the procedure. • Communication about CIEDs should be a part of a larger conversation about patients’ goals of care. The role of the clinician is to help patients determine how the benefits and burdens of device therapy align with their desired outcomes for their health care.    This new guide on how to handle requests to deactivate devices in dying patients provides a thorough review of the topic, practical advice, and useful summaries of basic principles. It balances well the rights of patients and the rights of physicians and highlights common misconceptions. Although the paper does not make for light reading, it serves as an outstanding reference to health care providers and patients themselves when this difficult situation is encountered.    Overall, the guide is a great contribution. However, making the case that turning off a pacemaker in a patient who is pacemaker dependent is not the same as euthanasia (from a legal or ethical standpoint) does not make the action any easier. It is likely that despite this clarification, several physicians will still refuse to turn off a pacemaker in a dependent patient. The authors reference a survey that found that only 10% of clinicians who care for patients with CIEDs view pacemaker deactivation in a pacemaker- dependent patient as a form of assisted suicide or euthanasia. This number seems low, and although the guide informs physicians who refuse to deactivate devices that they are responsible for finding a colleague who is willing to do so, it is not clear what happens when there is no one in a particular hospital who is willing to do so. Sincerely, Bradley P. Knight, MD, FACC, FHRS Editor-in-Chief, EP Lab Digest